Above average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Lewisburg Healthcare Center during CMS and state inspections, most recent first.
A resident with cerebral palsy, autism, a PEG tube, and an NPO order was given a cola by a staff member unfamiliar with the resident, after the resident requested the drink. The resident, who had moderate cognitive impairment and had been determined incapacitated, drank the cola and immediately coughed, and the episode was documented as a choking event. Review of records showed other residents had orders for nectar- and honey-thick liquids, and the facility acknowledged that a CNA provided the cola without checking the Kardex and diet orders. Subsequent staff interviews showed that staff could describe the need to verify diet orders or involve nursing before providing food or drink, but prior training materials did not explicitly address checking and following physician diet orders before giving residents any food or fluids.
The facility failed to ensure residents knew where the state survey results were located. During a resident council meeting, residents with BIMS scores of 14 or higher said they had never been told the location of the survey results, and both the activities coordinator and social worker stated they had not discussed it with residents. Resident council minutes also did not show any discussion of the survey results book or its location.
Unclean resident bathrooms remained unaddressed. Multiple resident bathrooms had dried brown spots, yellow and brown spots, residue buildup, and torn tissue paper scattered on the floor, and later walkthroughs showed several bathrooms still had not been cleaned over a 24-hour period. Staff, including an employee, the Infection Control Preventionist, and the Housekeeping Manager, acknowledged the unclean conditions and could not explain why the bathrooms had not been cleaned.
Infection control practices were not maintained during meal service and resident care. A CNA touched a resident's ready-to-eat brownie and cornbread with bare hands and handled a straw with bare hands before placing it in the resident's drink, while other staff in the dining room were also observed touching ready-to-eat foods with bare hands instead of using utensils. Two residents had wheelchairs with cracked and torn upholstery exposing inner padding, and staff acknowledged the equipment could not be cleaned to prevent infection. During lunch tray pass, hand hygiene for residents was not completed as expected.
A resident was sent out for dialysis wearing a hospital gown after his personal clothing and blanket were lost or not returned following laundry tagging. He reported ordering shirts, pants, and a quilt, but continued to have only gowns available, and staff said he routinely wore a gown when leaving the facility. The grievance about the missing items was handled in house and was not entered on the grievance or reportable logs.
An unlocked, unattended laptop on a med cart displayed a resident’s prescribed medications, and an unlocked wall-mounted tablet on the 600 hall displayed 13 resident names and pictures with access to more information. An LPN confirmed she had walked away without locking the computer, and an RN confirmed staff are trained to lock or log off devices before leaving them unattended.
Residents were not informed that grievances could be filed anonymously or where to submit them, as confirmed in resident council interviews and staff statements. A resident also reported missing clothing and a blanket, was observed wearing a hospital gown on multiple days, and the Social Worker said she did not file a grievance for the missing items; the grievance log had no entry for that concern.
A resident with documented hearing deficits was observed without the prescribed hearing aid in the right ear as ordered by the physician. Staff verified the resident had not worn the device for a long time, and the DON acknowledged the finding. The hearing aid was later found in the med room.
An unidentified pink, creamy substance was found in a medicine cup in a resident’s bathroom during a walk-through. The resident did not know what it was, an LPN said it looked like barrier cream and should not have been there, and the DON later could not identify the substance.
Incomplete Nurse Staff Posting: The facility failed to ensure the daily nurse staff posting included the total number of hours worked. During record review, multiple postings were found missing the total hours worked, and the Administrator confirmed the new forms used by the facility did not include total hours.
Incomplete and inaccurate resident medical records were identified for three residents. One resident’s POST form was invalid because it lacked the physician’s required signature, another resident’s controlled pain medication was administered but not documented timely on multiple occasions, and a third resident’s chart incorrectly stated that a hearing aid was in place when it was actually found in the medication room. The DON acknowledged each record issue.
The facility failed to maintain accurate documentation for narcotic medication administration across three medication carts, affecting multiple residents. The policy requires controlled drugs to be verified and signed by both oncoming and off-going nurses at each shift change. However, numerous entries were missing signatures or had incorrect card counts. Interviews with LPNs and the DON confirmed these discrepancies, and an audit was underway to address the issue.
The facility failed to maintain accurate medical records for two residents regarding RSV vaccine consent. Both residents' records showed the vaccine was administered, with verbal consent obtained and witnessed, but the consent forms lacked dates. The residents' representatives expressed confusion, and the DON acknowledged the issue.
A facility failed to maintain proper infection control during medication administration when an LPN placed medications directly on a resident's over-the-bed table without using a barrier. The LPN admitted to using an activity sheet instead of the provided wax paper barrier. The facility lacked a formal policy on barrier use, although it was considered common sense by staff.
A facility failed to notify a resident's MPOA before administering an RSV vaccine and regarding the resident's shingles diagnosis and treatment. The MPOA was unaware of these actions, despite records indicating verbal consent for the vaccine. The DON acknowledged the oversight after an audit revealed the issues.
Failure to Follow NPO and Thickened Liquid Orders Resulting in Choking Episode
Penalty
Summary
The deficiency involves the facility’s failure to follow a physician’s order for a resident who was ordered nothing by mouth (NPO). A resident with cerebral palsy and autism, who had a PEG tube and an NPO order dated 04/21/25, was given a cola by a staff member who was not familiar with the resident. The resident, who had been determined incapacitated on 04/21/25 and had a BIMS score of 9 indicating moderate cognitive impairment, requested the cola, took a drink, and immediately coughed. Nursing documentation noted that the resident was aware of her NPO status but still requested the cola, and that the cola was removed after the choking episode and the resident was taken to the nurse for assessment. The incident was documented in nursing notes as a choking episode that occurred during activities when the resident was in the dining room post-activity, before the noon meal. Record review also showed that several other residents in the facility had orders for specialized liquid consistencies, including nectar thick liquids and honey thick liquids. The facility acknowledged that a CNA provided the soft drink without checking the Kardex and diet orders. Interviews conducted later with various staff members, including dietary, nursing assistants, activities, therapy, environmental services, maintenance, and administration, revealed that staff could verbalize the need to verify a resident’s diet or refer the request to nursing before providing food or drink. However, the documentation provided from prior staff trainings did not specifically address the requirement to follow physician orders and to check those orders before giving residents any food or liquids.
Residents Not Informed of Survey Results Location
Penalty
Summary
The facility failed to ensure residents knew the location of the state inspection results. During a resident council meeting, residents with BIMS scores of 14 or higher were asked whether they knew where the survey results were located, and the resident council president stated he had never been told where they were located; the other residents in attendance agreed. In interviews, the activities coordinator stated that the State Survey Results book and its location are discussed upon admission, but she had not discussed the location of the state survey results book and would make sure to add it to council meetings. The social worker also stated that she had not discussed the location of the state survey results with residents. Review of resident council meeting minutes did not show any discussion of the state survey results book or its location.
Unclean resident bathrooms remained unaddressed
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment in multiple resident bathrooms. During observations and interviews, Resident #57’s bathroom had dried brown spots on the floor around the base of the toilet and on the toilet seat. Resident #21’s bathroom had yellow and brown spots on the toilet seat. Resident #81’s bathroom had dried brown liquid spots splattered on the wall above the light switch and dried brown spots on the floor around the toilet. Resident #12’s bathroom had residue built up on the back of the toilet tank, multiple pieces of torn tissue paper scattered across the bathroom floor, and wet brown and yellow spots on the toilet seat. Facility walkthroughs later showed that the bathrooms in rooms 204, 205, and 207 still had not changed and had not been cleaned over a 24-hour period. An employee acknowledged the unclean bathrooms in rooms 205 and 207 and stated she did not know the cleaning schedule for resident rooms. The Infection Control Preventionist also acknowledged that the bathrooms in rooms 204, 205, and 207 had not been cleaned over a 24-hour period and did not know the cleaning schedule for residents' rooms. The Housekeeping Manager later acknowledged those rooms had not been cleaned and stated there were three housekeeping employees daily to clean all resident rooms and bathrooms, but could not explain why those bathrooms were not cleaned on 01/12/26 or 01/13/26.
Infection Control Lapses During Meal Service and Resident Care
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections during meal service and resident care. During tray delivery and meal set up in Resident #61's room, CNA #77 touched the resident's brownie and cornbread with bare hands and removed the straw from its package by touching both the end and middle of the straw with bare hands before placing it into the resident's drink. When interviewed, CNA #77 stated that was how she had always done it and then said she maybe should have been wearing gloves. Additional observations showed resident equipment that could not be properly cleaned. Resident #81's wheelchair had cracked edges and tears in the plastic cover on the right armrest, exposing the inner padding, and Resident #58's wheelchair had cracks and tears across the backrest with exposed inner padding. The Infection Preventionist acknowledged the wheelchair had cracked edges and a tear in the plastic right arm pad and agreed the chair had exposed padding and could not be cleaned to prevent infection. In the main dining room, AA #83 and NA #78 were also observed touching brownie and cornbread with bare hands while assisting with meal setup, despite stating that utensils should be used. During lunch tray pass on hall 600, trays were delivered to six residents, and NA #36 stated that residents are supposed to receive hand hygiene but that it was not done that day.
Resident Sent Out in Hospital Gown After Missing Clothing Was Not Returned
Penalty
Summary
The facility failed to protect a resident’s dignity when he left the building for outside appointments while wearing a hospital gown. Resident #5 reported that he had not had his own clothes since admission because items he ordered were sent to laundry for labeling and were not returned to him. He stated he had ordered three shirts, two pairs of pants, and a blue quilt, and that only two shirts had been replaced after he reported the missing items. He was observed wearing a hospital gown on multiple days, including when he went out for dialysis three times per week, and he stated he preferred to wear clothes to dialysis and outside his room. The record showed a grievance dated and marked resolved for a bag of clothing items that was lost and never tagged, with clothing replaced, but the grievance was not entered on the grievance log or reportable log. The Activities Director said she was notified of missing items and ordered replacement clothing, while the Social Worker said she did not file a grievance and had handled the issue in house by emailing the Activities Director. Laundry staff reported that new shirts had come through the laundry, were marked with the resident’s name, and then were never seen again. The Administrator reviewed documentation showing only two shirts and one pair of women’s pants had been ordered, while the resident continued to report missing pants and a blanket.
Unsecured Electronic Devices Exposed Resident Information
Penalty
Summary
The facility failed to secure and keep confidential residents’ personal and medical information when private information was left visible on an unlocked, unattended laptop on top of a medication cart near the nurse’s station and on an unlocked, unattended wall-mounted tablet on the 600 hallway. Resident #67’s prescribed medications were visible on the laptop to any passerby, and the laptop and medication cart were identified by LPN #72 as hers, with the nurse confirming she had walked away without locking the computer to protect privacy. The wall-mounted tablet displayed the welcome screen with CNA #5’s name and showed 13 resident names and pictures, and it was possible to click on a resident’s name to view additional information. RN #20 confirmed staff are trained to lock or log off devices before walking away, and the facility’s confidentiality policy stated that clinical records are confidential and electronic records must be closed when leaving a computer unattended.
Residents Not Informed of Anonymous Grievance Process and Missing Item Concern Not Logged
Penalty
Summary
The facility failed to ensure residents were informed of their right to file grievances anonymously and to know where to file them. During a resident council meeting, residents with BIMS scores of 14 and higher stated they did not know they could file a grievance anonymously and did not know the location of the grievance drop-off box outside the Social Worker's office door. Staff interviews confirmed that the activities coordinator discussed resident rights and grievances but did not discuss anonymous filing or the drop-off location, and the Social Worker stated she had not discussed anonymous grievance filing with residents and said that was usually done during resident council meetings. A review of resident council meeting minutes for the past year found no discussions about how to file a grievance anonymously. The report also identified Resident #5 as a resident with unresolved concerns about missing clothing and a blanket. He reported that clothing he ordered was sent to laundry for labeling and never returned, that replacement shirts were delivered, and that he had not seen the pants or blue quilt he ordered. He was observed wearing a hospital gown on multiple days and stated he did not have pants and wanted clothing to wear to dialysis and outside his room. Interviews with the Activities Director, Social Worker, Laundry staff, Nurse Aide, and Administrator showed the facility was aware of the missing items and had attempted to handle the matter in-house. The Social Worker stated she did not file a grievance for the missing clothing items, and the grievance log and reportable log contained no grievance for Resident #5. Documentation reviewed included a prior grievance form for another resident involving lost clothing that had been resolved, as well as emails and invoices related to Resident #5's clothing orders, but the resident's reported missing pants and blanket were not reflected in the grievance log.
Failure to Provide Prescribed Hearing Aid
Penalty
Summary
The facility failed to ensure that a resident received the prescribed assistive device for hearing. Resident #76 was documented on 01/12/26 as having difficulty hearing and was care planned for hearing deficits. During an observation on 01/14/26, Resident #76 was found without the hearing aid in the right ear as ordered by the physician. When asked by Employee #32 when the hearing aid was last worn, the resident stated it had been a long time. Employee #31 and Employee #32 verified the observation at the time it was made, and the Director of Nursing acknowledged it during the same observation. Employee #72 later found the resident's hearing aid in the medication room.
Unidentified Creamy Substance Left in Resident Bathroom
Penalty
Summary
The facility failed to keep the resident environment as free of accident hazards as possible when an unidentified pink, creamy substance was found sitting in a medicine cup on the back of the sink in Resident #21’s bathroom. During the initial walk-through, the resident stated she did not know what was in the cup. An LPN later observed the cup, stated it looked like barrier cream, and said it should not have been there, then removed it from the room. The DON later reviewed the item but was unable to identify the pink creamy substance found in the resident’s bathroom.
Incomplete Nurse Staff Posting
Penalty
Summary
The facility failed to ensure the daily nurse staff posting included the total number of hours worked. During record review on 01/14/26 at 12:10 PM, the nurse staff posting was reviewed and several dates were found to be missing the total number of hours worked, including 11/27/25, 11/28/25, 12/13/25, 12/14/25, 12/24/25, 12/25/25, 01/02/26, and 01/03/26. During an interview on 01/14/26 at 12:49 PM, the Administrator stated the facility switched to the new forms sometime in September and confirmed the new forms did not include the total number of hours.
Incomplete and Inaccurate Resident Medical Records
Penalty
Summary
The facility failed to maintain complete and accurate medical records for three residents. For one resident, a Portable Orders for Scope of Treatment (POST) form indicated the resident chose DNR status and limited interventions, and the form was signed by the resident’s legal representative, but it was not signed and dated by the physician. The directions for completing the POST form stated the physician signature was mandatory and that a form lacking the signature was not valid. The DON acknowledged that the form was not signed and dated by the physician, making it invalid. For another resident, orders showed oxycodone-acetaminophen 5-325 mg every 6 hours, and review of the Medication Administration Audit Report and the Individual Residents Controlled Substance Administration Record showed the medication was given on time, but on at least 12 occasions it was not documented as administered for 2 to 4 hours after administration. The DON confirmed the medication had not been documented timely. For a third resident, an employee documented that the resident’s hearing aid had been placed in the right ear, but observation and verification showed the resident did not have the hearing aid in the right ear and that it was located in the medication room. The DON verified and acknowledged the inaccuracy of the medical record.
Inaccurate Documentation of Narcotic Medication Administration
Penalty
Summary
The facility failed to maintain accurate documentation for the administration and dispensing of narcotic medication across three medication carts, potentially affecting more than a limited number of residents. The facility's policy requires controlled drugs and count sheets to be verified and signed by both the oncoming and off-going nurses at each shift change. However, record reviews and staff interviews revealed numerous instances where this procedure was not followed, leading to incomplete and inaccurate records. For the 100 Hall Medication Cart, several entries were missing the off-duty nurse's signature, and in some cases, the total number of cards was either missing or incorrect. Similar issues were observed with the 500 Hall Medication Cart, where entries lacked signatures from both on-duty and off-duty nurses, and some entries had illegible or missing card counts. The 600 Hall Odd Medication Cart also had multiple entries with missing signatures, indicating a systemic issue with the documentation process. Interviews with LPNs and the DON confirmed the discrepancies in the narcotic logbooks. The DON acknowledged the incomplete and inaccurate records and stated that the facility was working to address the issue. The Regional Director of Operations also confirmed that an audit was underway to resolve the narcotic book issues, highlighting the need for improved accuracy in the facility's documentation practices.
Inaccurate Medical Records for RSV Vaccine Consent
Penalty
Summary
The facility failed to maintain accurate medical records for two residents regarding the Respiratory Syncytial Virus (RSV) vaccine consent. For one resident, the medical record indicated that the RSV vaccine was administered in the left deltoid, and a verbal consent was obtained from the resident's representative, witnessed by two staff members, but the consent form lacked a date. The resident's representative expressed confusion during an interview, stating they were contacted for consent again despite believing the vaccine had already been administered. Similarly, for another resident, the medical record showed the RSV vaccine was given in the right deltoid, with verbal consent obtained and witnessed by two staff members, yet the consent form also lacked a date. The Director of Nursing acknowledged the absence of dates on the RSV consent forms during an interview.
Infection Control Deficiency in Medication Administration
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by an incident involving the improper administration of medication to a resident. During a facility tour, an LPN was observed administering medication to a resident without using a proper barrier on the over-the-bed table. The medications, including Refresh Tear Solution, Trelegy Inhaler, and Ipratropium Bromide Nasal Solution, were placed directly on the table, which is not in line with infection control practices. The LPN admitted to using an activity sheet as a barrier instead of the wax paper barrier provided on the medication cart. Further investigation revealed that there was no formal facility policy regarding the use of barriers during medication administration, although it was considered common sense by the staff. The Director of Nursing and a Corporate Registered Nurse acknowledged the oversight and confirmed that the medications should have been placed on a barrier. Despite a subsequent Medication Barrier Audit indicating satisfactory results, the initial failure to use a barrier during medication administration was a clear deficiency in the facility's infection control practices.
Failure to Notify MPOA of Vaccination and Medical Condition
Penalty
Summary
The facility failed to notify the Medical Power of Attorney (MPOA) for a resident prior to administering vaccinations and regarding a change in the resident's condition and treatment for shingles. The resident was determined to lack the capacity to make medical decisions, necessitating the involvement of the MPOA. Despite this, the MPOA was not informed about the administration of the RSV vaccine, nor was she notified about the resident's shingles diagnosis and subsequent treatment, which included medication and isolation. The MPOA confirmed during interviews that she was unaware of the RSV vaccination and the shingles diagnosis and treatment. The facility's records indicated that verbal consent for the RSV vaccine was obtained, but the MPOA denied this, stating she was only contacted about a COVID-19 vaccine. The Director of Nursing acknowledged the oversight and initiated a grievance after the issues were brought to light during an audit.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 102 citations issued within 25 miles in the last 12 months — including the 2 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Ronceverte
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Seneca Trail Healthcare Center | 1.2 mi | ★★★★★ | 18 | 0 |
| White Sulphur Springs Center | 12.7 mi | ★★★★★ | 20 | 1 |
| Summers Healthcare Center | 18.9 mi | ★★★★★ | 27 | 1 |
| Rainelle Healthcare Center | 21.5 mi | ★★★★★ | 6 | 0 |
| Lindside Healthcare Center | 21.9 mi | ★★★★★ | 24 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Lewisburg Healthcare Center.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.